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[FOR OFFICE USE: LPPLICATION FOR WELL OR PUMP PERMIT PERMIT NO. <br /> (Complete in Triplicate) Date Issued: �-- <br /> r} PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> APPLICATION IS HEREBY MADE TO THE SAN JOAQUIN LOCAL HEALTH DISTRICT FOR A PERMIT TO PERFORM <br /> THE WORK STATED HEREON. THIS APPLICATION IS MADE IN COMPLIANCE WITH COUNTY ORDINANCE <br /> NO. 1.862 AND RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> JOB ADDRESS/LOCATION: r. l3 CENSUS TRACT: J _ <br /> OWNER'S NAME• ,, P HONE: F.73- L7 <br /> ADDRESS: 3. u CITY: y <br /> CONTRACTOR'S NAME: chi LICENSE PHONE: <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER 19ELL PUBLIC WATER WELL j I TEST WELL /� <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL / / INDUSTRIAL WATER WELL <br /> CATHODIC PROTECTION WELL / / GEOPHYSICAL WELL Ll OTHERTANX SE <br /> NEW WELL: SEWAGISTECDISPOSE TO AL ST:D .SEPTICESSP00 EPAGERPIT� PRIVY <br /> REPAIRS: TYPE OF REPAIRS: I <br /> o <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: <br /> PLOT PLAN: SHOW ON REVERSE SIDE <br /> k I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN <br /> ACCORDANCE WITH THE PROVISIONS OF THE LAWS OF THE STATE OF CALIFORNIA, THE ORDINANCES OF THE <br /> COUNTY OF SAN JOAQUIN, AND THE RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> SIGNED: �• (: . 1 5 CONTRACTOR: <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I r <br /> APPLICATION ACCEPTED BY: , _// �r DATE: <br /> ADDITIONAL COMMENTS: r <br /> PHASE II PHASE III FINAL <br /> t INSPECTION BY: INSPECTION BY: 5> <br /> E H 1426 SAN JOAQUIN LOCAL HEALTH DISTRICT 1/72 1M <br /> �0.DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />